ECG Case 100

Rate:

Rhythm:

Axis:

Intervals:

Additional:

• ST Elevation in leads aVR & aVL (<1mm font=””>
• Upsloping ST depression in leads V2-6 
• Flat ST depression in the inferior leads
• Prominent T waves in leads V2-4 

Interpretation:

• Features consistent with a De Winter pattern
  • Suggesting potential LAD pathology
  • DDx Demand ischaemia / perfusion mismatch

Given the patients age and medical history broader differentials for shock and ischaemic ECG features would be:

• PE
• Sepsis
• Endocrine – Sheehan Syndrome (postpartum pituitary gland necrosis)

Following review of the initial ECG urgent cardiology input was obtained and an emergent CTPA was performed to exclude PE as a potential cause.

On return from a negative CTPA the patient complained of further chest pain, repeat ECG below:

Clear anterolateral ST elevation and inferior ST depression. The patient was transferred for urgent angiography which showed a 90% mid LAD lesion treated with bioresorbable stent.

Subsequent CTPA revealed a coronary artery dissection as the cause for the acute LAD lesion.

Spontaneous Coronary Artery Dissection (SCAD)

This is a rare phenomena occurring in ~4% of all acute MI’s. Approximately 90% of cases occur in females and it accounts for 1/4 of MI’s in the under 50 yr old age group. Recurrence rate is between 13-18%.
There are multiple risk factors including:

• Fibromuscular dysplasia
• Pregnancy
• Connective tissue disorders
• Systemic inflammatory conditions
• Intense exercise
• Intense emotional stress
• Labour and delivery
• Valsalva-like events
• Sympathomimetic use